SUBCLINICAL SECONDARY ADRENAL INSUFFICIENCY IN A PATIENT WITH MALNUTRITION – INTERRELATIONSHIP OF NUTRITION AND ENDOCRINOLOGY

Abstract

INTRODUCTION
The syndrome of protein-calorie malnutrition (PCM) entails not only nutritional deficiencies, but also affects the levels of various hormones. Some vulnerable patients might have maladaptive responses and could lead to clinical catastrophic outcomes if left undetected.

CASE
A 41-year-old Thai man with underlying major depression presented with weight loss and nonhealing ulcer at the left heel for 3 months. Nutrition-focused physical examinations were consistent with severe PCM and multiple micronutrient deficiencies especially zinc deficiency. He was hospitalized and treated with combined enteral and parental nutrition. During admission, morning cortisols were done as a part of investigations. The cortisol results were unexpectedly low at the level of 3.7-4.7 µg/dL. The patient failed to respond to a 250 µg ACTH stimulation test (peak cortisol at 17 µg/dL) and plasma ACTH showed normal level. Other pituitary hormones were normal. MRI pituitary gland showed only a microadenoma 5 mm at left lobe of pituitary gland. Oral prednisolone was given and continued for 3 months after discharge. Subsequent ACTH test at OPD showed reversible adrenal insufficiency and prednisolone was tapered off. The patient gradually recovered from malnutrition and mental illness.

CONCLUSION
Endocrine changes due to malnutrition are part of an adaptive mechanism. Most malnourished patients have normal or high cortisol levels; however, some patients might have adrenal insufficiency from maladaptive responses to stress. Early detection and management of adrenal insufficiency should be addressed in these patients.